ORTHODONTICS, PERIODONTICS, IMPLANT and PROSTHODONTICS Fatma YILDIRIM1, Orhan AKSOY1, Utku Gaye DİKME GÜVELİ2, Erol AKIN3 ABSTRACT ÖZET

Aydın Dental - Year 3 Issue 1 - April 2017 (17-20) CASE REPORT

A MULTIDISCIPLINARY ORTHODONTIC CASE: ORTHODONTICS, PERIODONTICS, IMPLANT AND PROSTHODONTICS Fatma YILDIRIM1, Orhan AKSOY1, Utku Gaye DİKME GÜVELİ2, Erol AKIN3 ABSTRACT ÖZET

Diastemas are frequent orthodontic problems caused by Diastemalar; diş kaybı, kama lateral, süpernümerer diş, multiple etiologies which can be physiologic and dentoalveolar belirgin frenulum ve labial dental segmentin proklinasyonu like missing tooth, peg lateral, supernumerary teeth, prominent gibi fizyolojik nedenlerle veya patolojik sebeplere bağlı frenulum, proclination of the labial dental segment; or self- olarak sık görülen ortodontik problemlerdir. Yetişkinlerde inflicted pathologies. The continuing presence of an anterior anterior diastemanın varlığı, sıklıkla estetik bir sorun olarak diastema in adults, has often been considered as an aesthetic kabul edilir. Bu vakada, yetişkin bir hastada, diş kaybına ve problem. In this case, a multidisciplinary treatment of an belirgin labial frenuluma bağlı ortaya çıkan diastemanın; adult patient who had a missing tooth and a prominent upper ortodontik, periodontal, implant ve protetik işlemlerini içeren labial frenulum, which includes orthodontics, periodontics, multidisipliner bir tedavisi sunulacaktır. implants and prosthetics will be presented. Anahtar Kelimeler: Diastema, labial frenulum, Keywords: Diastema, Labial Frenulum, Multidisciplinary multidisipliner tedavi Treatment

1 Istanbul Aydın University, Faculty of Dentistry, Department of Orthodontics 2 Istanbul Aydın University, Faculty of Dentistry, Department of Periodontics 3 Private Practice, Orthodontist

INTRODUCTION seek closure of a diastema for aesthetic reasons. Many treatment options have been A space between adjacent teeth is called a used, varying from restorative procedures diastema. Diastemas are frequent orthodontic to surgery (frenectomy) and orthodontics. problems caused by multiple etiologies which A carefully developed differential diagnosis can be physiologic and dentoalveolar like allows the practitioner to choose the most missing tooth, peg lateral, supernumerary effective treatment objectives. In this case, a teeth, prominent frenulum, proclination of multidisciplinary treatment of an adult patient the labial dental segment; or self-inflicted who had a missing tooth and a prominent upper pathologies.1 Midline diastema refers to labial frenulum, which includes orthodontics, anterior midline spacing between the two periodontics, implants and prosthetics will be central incisors. Midline diastema occurs in presented. approximately 98% of 6 year olds, 49% of 11 year olds and 7% of 12–18 year olds.2 It CASE REPORT is a part of normal dental development during mixed dentition which is called ugly duckling A 26 year old female reported to the stage by Broadbent.4 It is a self-correcting orthodontic clinic with the chief complaint of anomaly after the eruption of the permanent upper jaw midline diastema. She has Angle canines. The continuing presence of a midline Class I malocclusion and diastemas due to diastema is not physiologic and considered missing upper left second premolar teeth and as an aesthetic problem in adults. Numerous prominent upper labial frenulum attachment. etiologies have been proposed for maxillary In lateral cephalometric examination, we midline diastema including tooth size or jaw determined skeletal Class I relationship size discrepancies, parafunctional habits, and normal vertical pattern. The patient’s tooth loss, periodontal disease, deep bites, past medical and dental history were not aberrant labial frenulum attachments and contributory; but in family history, she noted maxillary midline pathologies. 3, 5-12 that her sister also had upper prominent labial frenulum and this information led us to think The frenulum is a mucous membrane fold that that genetic factors can be contributing factor attaches the lip and the cheek to the alveolar in diastema etiology. (Fig. 1) mucosa, the gingiva, and the underlying periosteum3. The aberrant labial frenulum is a problem which creates midline diastema and it can be treated by frenectomy or by frenotomy procedures. These procedures are technically different from each other. Frenectomy is the complete removal of the frenulum, including its attachment to the underlying bone, while frenotomy is the incision and the relocation of the frenal attachment 3.

A healthy and attractive smile is very Figure 1. The initial photographic records important in today’s society. Many patients

18 Fatma YILDIRIM, Orhan AKSOY, Utku Gaye DİKME GÜVELİ, Erol AKIN

Multidisciplinary treatment which includes canine to canine on lower ach and between orthodontics, periodontics, implants, and first premolars on upper arch. Implant surgery prosthetics was planned for the case. was performed and a week later sutures were Orthodontic treatment was started at first and removed. A removable Hawley appliance the midline diastema was closed with fixed used for retention until the osseointegration bonded braces and mechanics. The space process was complete. After osseointegration, caused by tooth extraction was maintained the patient was rehabilitated with crown for dental implant procedures. Before the prosthesis. At the end of the treatment, the finishing phase, when the upper midline upper third molars were extracted. (Fig. 4) diastema closed, patient was directed to the periodontology department. Because of the width and thickness of the frenulum attachment frenecomy was chosen instead of frenotomy. Frenectomy was carried out by periodontist under local anesthesia with incision using No. Figure 4. The photographic records after 1 15 Bard Parker blade. Sutures were placed year retention period. and periodontal pack was placed for a week. Healing was successful and pleasant. (Fig. 2, DISCUSSION 3) In the recent times, due to increasing expectations of the patients for an esthetically and functionally stable treatment result, an interdisciplinary treatment will yield the best result for the patient and the clinicians. Evaluating the patient history prior to treatment is vital for the treatment planning. Figure 2. The photographic records before In this case, we determine the upper labial upper labial frenectomy and after healing. frenulum as an etiological cause of upper midline diastema. Patient also stated that her sister has a similar midline diastema hence it suggests that genetic factors may be contributing factor in this etiology. Gaas et al.13 reported that, heritability of maxillary midline diastemas was estimated to be %32 in white population and % 0,4 in black population. According to their study, the pedigree data suggest an autosomal dominant mode of inheritance for maxillary midline Figure 3. The panoramic radiographs after diastema and a possible genetic influence in orthodontic debonding and implant surgery. the expression of maxillary midline diastema in both the black and the white sample After these procedures, braces were removed populations. In this case, the diastema was and fixed lingual retainers were bonded closed orthodontically and then frenectomy

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